Headlines about "Health plan costs - managed care"

Gathered from the web by the editors at BenefitsLink.com.
[Opinion] Fee-for-Service Model: Culprit Behind Exponential Health Care Cost Growth?
"Moving away from fee-for-service requires realigning the care delivery and payment incentives in the health care system. [Reimbursement should be] based on the quality and utility of care provided, not just the sheer volume of services. This idea -- paying for 'value over volume' or 'paying for performance' -- is now a common refrain in the world of health policy. Some experts even go so far as to say that too much care can be detrimental to health, such as unnecessary or redundant medical imaging scans[.]" (The Atlantic)

AHIP Says Health Insurers Will Continue to Innovate
"'To say that health insurers will go out of business by 2020 is totally inconsistent with what's going on in the real world,' [says Karen Ignagni, President and CEO of the 'America's Health Insurance Plans' trade association]. 'Since the 1990s, health plans have been the engine of change. All around the country, you can see the evidence of how health plans are innovating in any number of areas.'" (Managed Care)

Official Report on Medicare: Text of the 2012 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds (PDF)
"The financial outlook for Medicare is ... uncertain because some provisions of current law that are designed to reduce costs may not be sustained. The clearest example of this issue is the sustainable growth rate ... formula for physician fee schedule payment levels. The projections in this report assume that, as required by current law, CMS will implement a reduction in Medicare payment rates for physician services of more than 30 percent at the start of 2013. However, it is a virtual certainty that lawmakers, cognizant of the disruptive consequences of such a sudden, sharp reduction in payments, will override this reduction just as they have every year since 2003." (The Boards of Trustees, Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds)

[Opinion] State Health Insurance Mandates Now Total 2,262, Costs Go Up for Everybody
"Based on our annual analysis, mandated benefits currently increase the cost of basic health coverage from slightly less than 10 percent to more than 50 percent, depending on the state, specific legislative language, and type of health insurance policy." (The Council for Affordable Health Insurance)

Health Plans in Michigan Get Creative With Their Pharmacy Benefits Management
"Michigan health plans are coming up with creative ways to manage their pharmacy benefits ... 'With clinical guidelines being encouraged by health plans, the pharmaceutical industry will see opportunities to advocate for their drugs to be used in treatment plans[.]'" (HealthLeaders-InterStudy)

Next Steps for Accountable Care Organizations
"This new approach is already affecting how other health plans pay providers and resulting in a number of ACO contracts between providers and private health plans. . . . This Health Policy Brief provides an overview of ACOs, their origins, and the current status of adoption by Medicare and private health insurance plans." (Health Affairs)

[Opinion] PBM Merger Would Mean More Bad News for Consumers
"Small and independent pharmacies may not fit into the [pharmacy benefit manager] industry's vision for the future. But community pharmacies and pharmacists are the most affordable and accessible health care provider in many communities -- and underserved communities in particular. Certainly their loss will have an adverse affect on patient care and outcomes." (Eva M. Clayton in the Huffington Post)

Are Accountable Care Organizations a Way to Fix a Fragmented and Expensive Health Care System?
"While health reform's primary focus on [Accountable Care Organizations] revolves around Medicare, many insurance carriers now have or are in the process of developing ACO options for the commercial sector. In fact, some ACOs have been around even before they recently began to gain more attention . . . ." (BenefitsPro)

A Merger Wave Hitting Health Care
"[Big managed health-care companies], which try to coordinate patients' medical providers to keep a lid on costs, are facing the double whammy of market saturation and margin-squeezing health-care reform. As a result, giants like Aetna, Cigna and Humana have started snapping up smaller players to keep earnings growth alive." (The Wall Street Journal)

Study Shows Potential Savings from Enrolling Dual Eligible Beneficiaries in Managed Care Plans
"A new study . . . examines the health care quality and savings potential of health plans and other care coordination models for Medicare/Medicaid dual eligibles. The study documents the potential savings of specific strategies used by health plans and other coordinated care models." (America's Health Insurance Plans)

Narrow-Network HMOs Are the New Cost-Cutting Tool
"These plans offer participants fewer choices, which enables the network to reduce its premiums for both employers and employees. High-cost doctors and diagnostic facilities are simply removed from the insurance roster and become inaccessible for the average subscriber." (Governing)

Success Factors in Five High-Quality, Low-Cost Health Plans
"Because employers are primarily responsible for arranging the health insurance coverage for their employees, there is market pressure for health plans to work with broader networks than they would otherwise want, which in turn interferes with the factors that lead to high performance." (The Commonwealth Fund)

Health Care Payment Reform: Analysis of Models and Performance Measurement Implications
"Recently, purchasers and insurers have been experimenting with payment approaches that include incentives to improve quality and reduce the use of unnecessary and costly services." (RAND)

Case Study: Employers and Providers Work Together to Improve Care and Lower Costs
"A Findlay, Ohio?based collaborative made up of local employers, physicians, and a hospital system pooled data from employee health claims to find variation in the quality and cost of treatment of their employees." (The Commonwealth Fund)

[Guidance Overview] Fiduciary Duties Not Implicated In Managed Care Rate Negotiations
Excerpt: "This unpublished Sixth Circuit opinion spotlights a business practice that rarely gets such close scrutiny. A Blue Cross subsidiary failed to meet its profitability numbers which inspired the idea to lower its reimbursement rates." (Roy Harmon III via Health Plan Law)

Evidence That Consumers Are Skeptical About Evidence-Based Health Care
Excerpt: "We undertook focus groups, interviews, and an online survey with health care consumers as part of a recent project to assist purchasers in communicating more effectively about health care evidence and quality. . . . We found many of these consumers' beliefs, values, and knowledge to be at odds with what policy makers prescribe as evidence-based health care. Few consumers understood terms such as 'medical evidence' or 'quality guidelines.' Most believed that more care meant higher-quality, better care." (Health Affairs)

[Opinion] Managed Health Care: Get Used to It
Excerpt: "We may not like it, but third parties -- the government and insurance companies -- won't be able to pay for all the care that people desire. Yet the aging of the population will ensure that medical costs will spiral. Douglas W. Elmendorf, director of the Congressional Budget Office, has said that the administration's cost-control proposals do not 'reduce the trajectory of federal health spending by a significant amount.' We need to think carefully about how to say no without breaking the better side of our health care institutions." (The New York Times; free registration required)

How Will Comparative Effectiveness Research Affect the Quality of Health Care?
Excerpt: "Building on the American Recovery and Reinvestment Act of 2009, health reform legislation would develop an infrastructure for the ongoing generation and dissemination of information on the comparative effectiveness, where 'comparative effectiveness' has been defined as the study of methods to prevent, diagnoses, treat, and monitor A clinical condition or improve delivery of care to assist consumers, clinicians, purchasers, and policy makers to make informed decisions to improve health care at both individual and population levels. The issue brief explores the concept and describes areas of controversy that need to be addressed to make comparative effectiveness research successful." (Urban Institute)

Patients Sue HMOs and Insurance Companies Over Lack of Inspections Before Hepatitis Crisis
Excerpt: "HMOs and health insurance companies have a reputation for being immune to patients' lawsuits, but an avalanche of court cases has been filed against them in connection with a hepatitis outbreak in Southern Nevada. Health maintenance organizations and health insurance companies must be held accountable for telling people which doctors they must use, say the attorneys of people who contracted or were exposed to hepatitis C at Dr. Dipak Desai's Las Vegas Valley endoscopy clinics." (Las Vegas Sun)

'Risk Sharing' Concept As Applied to Pharmaceuticals
Excerpt: "The concept of 'risk sharing' is a new idea that was in many cases discarded during the managed care backlash. But now that old idea is getting new attention among pharmaceutical and biotech companies as part of the larger effort to control healthcare costs. This article from the Biotechnology Healthcare Journal examines the new risk sharing and includes perspective from Milliman principals Bruce Pyenson and Kate Fitch." (Milliman)

[Opinion] When Americans Rejected Managed Health Care, They Didn't Know They Were Ending Wage Increases, Too
Excerpt: "Cost control is not, in fact, all pain and no gain. It's some pain in return for a fat raise." (The Washington Post; free registration required)

[Guidance Overview] Balance Billing Practices May Constitute Breach of Contract
Excerpt: "This district court opinion holds interest for health care providers and benefit fiduciaries alike. As against a motion to dismiss, the district court holds that the plaintiffs have stated a cause of action against the health care provider for balance billing, i.e., billing the balance 'owed' after their health plan paid the PPO discounted rate." (Attorney Roy F Harmon III in the Health Plan Law blog)

Private Health Insurance: Research on Competition in the Insurance Industry (PDF)
13 pages. Excerpt: "Health care providers and members of Congress have raised concerns that consolidation in the private health insurance industry may be resulting in less competitive markets and contributing to rising health insurance rates paid by consumers and employers. However, measuring the extent of changes in market competition over time or the effects of changes is challenging. . . . Despite [the] challenges, researchers have used the data available to study competition in health insurance markets, typically using one of two measures of competition: (1) HMO market concentration or (2) the number of HMOs in a market." (U.S. Government Accountability Office)

New York Laws Increase State COBRA Period and Age for Dependent Health Insurance Coverage (PDF)
3 pages. Excerpt: "On July 29, 2009, New York Governor David Paterson (D) signed into law three health reform bills -- one extending the period for state health coverage continuation rights from 18 to 36 months, one requiring insurers to offer continued coverage for unmarried adults through age 29 under their parent's individual or group health insurance policies, and one instituting a series of managed care reforms." (Buck Consultants)

Consumer Driven Health Plans Cover More Employees than HMOs, According to Survey Results
Excerpt: "Consumer Driven Health Plans (CDHPs) in the U.S. have surpassed HMO plans in covered employees, according to preliminary results released by United Benefit Advisors (UBA) from its 2009 UBA Health Plan Survey, a plan benchmarking poll with 17,655 plans from 12,316 employers reporting. According to a press release, CDHPs grew at a rate of 33.9% this past year and now cover more employees (15.4%) than HMO plans (13.6%)." (PLANSPONSOR.com; free registration required)

GAO Study Describes Cost-Sharing Requirements and Dollar Limits Under Federal Health Plan for Expensive 'Speciality' Drugs
11 pages. Excerpt: "Specialty prescription drugs are typically used to treat chronic or life-threatening conditions, such as multiple sclerosis and cancer, for which few other treatment options exist. . . . Costs for specialty prescription drugs are usually high, typically ranging from $1,200 to $40,000 for a 30-day supply. . . . To manage the high and rising costs of these drugs, some health plans have begun to require enrollees to contribute a greater share of their costs, such as by increasing the use of coinsurance. You asked us to examine the costs that FEHBP enrollees may incur for specialty prescription drugs." (U.S . Government Accountability Office)

Number of HMOs as of July 2008
Source: Healthleaders, Inc., Special Data Request, March 2009. (Kaiser Family Foundation)

Waste-Reduction Strategies Can Improve Health Care Quality With Reduced Costs
Excerpt: "In 'Imagining 16% to 12%: A vision for cost efficiency, improving health care quality, and covering the uninsured,' [Milliman sets] forth 'actuarial insights to help health care reformers develop better proposals' while reducing health care's share of the gross domestic product (GDP) from the current 16% to 12%. The Milliman team's strategies support those of the Obama Administration to reduce costly waste in health care by relying more on evidence-based medicine, using comparative effectiveness evaluations of new and existing treatments to identify those that are the most cost effective, setting quality standards and measures, making providers accountable for outcomes, encouraging informed patient choice, and promoting electronic medical records, among other steps." (Wolters Kluwer)

Impact of Two Employer-Sponsored Population Health Management Programs on Medical Care Cost and Utilization (PDF)
8 pages. Excerpt: "Conclusions: Our results suggest that the programs did not reduce medical cost in their first year, despite a beneficial effect on hospital admissions. If we had been able to include program fees, it is likely that the overall cost would have increased significantly. Although this study had important limitations, the results suggest that a belief that these programs will save money may be too optimistic and better evaluation is needed." (The American Journal of Managed Care)

Report on California Health Plans and Insurers
Excerpt: "Private health insurance carriers form the backbone of California's market-based health care system, providing coverage to 67% of its population. Health insurance carriers not only serve the privately insured, but also large portions of the publicly insured, in Medi-Cal, Healthy Families, Medicare, and other public programs. [Both the report and data files are linked from the target page.]" (California HealthCare Foundation)

[Guidance Overview] Hospital Not Entitled to Notification That Participant Was in COBRA Election Period
Excerpt: "Although apparently not raised by the hospital, the IRS COBRA regulations require an indemnity or reimbursement plan to make a complete response to any inquiry from a health care provider regarding a qualified beneficiary's right to coverage under a plan during the COBRA election period. However, this provision of the regulations refers only to indemnity and reimbursement plans -- HMOs (such as the one in this case) and other plans providing services (such as walk-in clinics) are not mentioned. Nevertheless, such plans may decide to adopt the disclosure practices in the IRS regulations for provider inquiries during the COBRA election period as a way to avoid disputes and potential liability (including possible state-law misrepresentation claims), even though these disclosures technically may not be required." (Employee Benefits Institute of America)

[Opinion] Alain Enthoven Responds on Reform of the Dutch System
Excerpt: "[In the JHPPL article by Pauline Vaillancourt Rosenau and Christiaan J. Lako, 'An Experiment with Regulated Competition and Individual Mandates for Universal Health Care: The New Dutch Health Insurance System' t]he authors referred to the Dutch reform as 'Enthoven-inspired.' Alain C. Enthoven, [known as the 'father of managed competition,' provides this response:] Don't leap to unfounded conclusions too quickly in this complex and important subject." (Physicians for a National Health Program)

Insurers Hire Radiology 'Benefits Managers' to Vet Scanning
Excerpt: "Health insurers are increasingly relying on outside firms to help rein in the skyrocketing costs of imaging scans like MRIs. But when these middlemen clash with doctors about what tests are needed, consumers can get caught in the crossfire. Big insurers including Aetna Inc., WellPoint Inc. and Cigna Corp. have hired so-called radiology benefits managers, or RBMs. Health plans say they want to ensure that doctors use high-tech scans only when it is clear that patients will benefit." (The Wall Street Journal)

The Changing Effect of Managed Care on Physician Financial Incentives
Excerpt: "Objective: To examine how managed care affects physician financial incentives to reduce services to their patients, particularly how this relationship has evolved over time and whether the effects of capitated managed care and noncapitated managed care are different. . . . Conclusion: Managed care and traditional indemnity plans were substantially more similar in their effects on physician incentives to provide care by 2004-2005 than they were just 3 years earlier. This should alleviate policy concerns that managed care is providing physicians with the 'wrong' financial incentives to provide care." (The American Journal of Managed Care)

Healthier Consumers, Customers and Communities: The Hannaford Dynamic (PDF)
4 pages. Excerpt: "This issue of our 2008 Perspectives series looks at how Hannaford Supermarkets used a 'quality paradigm' -- focusing on quality care, efficiency, evidence-based medicine and cost control to dramatically lower its health care spend while lifting employee satisfaction and perception of quality." (Towers Perrin)

Fight Back When Your Health Plan Says No
Excerpt: "Bernadine Healy, MD, former director of NIH and now health editor at US News & World Report, has written a chilling piece on how easy it is for insurers to deny claims. From the article, 'How Crafty Health Insurers Are Denying Care' . . . ." (Health Insurance Consumer Information)

Patients Suffer As Care, Coverage Limits Collide; Physicians Say Insurers Intrude on Treatment
Excerpt: "Increasing healthcare costs and an influx of expensive drugs and tests, combined with an aging population, set off a healthcare crisis in the United States. Contending with soaring costs, insurers changed the business of health care by requiring preauthorizations, mandating cheaper drugs, and tightening controls on treatment decisions. But among the first casualties of these changes, many physicians said, was the doctor-patient relationship." (Toledo Blade)

Insurers Using Radiology Benefit Managers To Cut Down on Unnecessary, Costly Imaging Procedures
Excerpt: "Health insurers are increasingly denying coverage for medical imaging procedures recommended by physicians that are judged to be unnecessary, in an attempt to reduce health care spending by $30 billion annually, according to a report released on Monday by America's Health Insurance Plans, Bloomberg/Hartford Courant reports." (Kaiser Family Foundation)

[Opinion] Health Insurance Companies and the Managed Care Roller Coaster
Excerpt: "'Managed care' is, to many, a nasty phrase. But the truth is that the insurer who understands that 'managing care' means making sure that customers get the high-quality care they need, when they need it, will save money. When it comes to health care, low cost and high quality go hand-in-hand. At the same time, 'managing care' means avoiding ineffective care." (The Century Foundation)

Mercer's HRadio Podcast, July 15, 2008
This week's lineup includes: News highlights; Understanding health care predictive models; Hurdles in the road to global pay; Socially responsible investing goes mainstream. Total time: 15:26 (Mercer LLC)

Graphs Show HMO Rate Increases by Region (PDF)
2 pages. Excerpt: "As U.S. companies begin to negotiate HMO plan rates for 2009, data from Hewitt Health Resource™ (HHR) -- a Web site that captures HMO rate information for 160 large companies representing approximately 1 million participants -- shows that initial 2009 HMO rate increases are averaging 11.8 percent, compared with estimates of 13.2 percent in 2008 and 11.7 percent in 2007." (Hewitt Associates)

2009 HMO Cost Hikes Down from 2008
Excerpt: "The good news for employers is that the rate of cost increases for health maintenance organizations (HMOs) is predicted to slow for 2009, but it is still out in front of inflation. That was the word from Hewitt Associates which gathered HMO rate data from its Hewitt Health Resource site, which features data from 160 large companies with about 1 million participants." (PLANSPONSOR.com; free registration required)

Quality Monitoring and Management in Commercial Health Plans (PDF)
Excerpt: "This survey of 252 HMOs found that almost all measure their performance on multiple indicators of quality and most use these data in quality improvement activities." (The American Journal of Managed Care)

[Guidance Overview] Futility Doctrine Applied in Aid of Class Action Claims Against HMO Defendants
Excerpt: "In this recent decision, the plaintiffs alleged that the defendant HMO's routinely overcharged for services. The defendants met these claims with a motion to dismiss for lack of subject matter jurisdiction and failure to exhaust administrative remedies. The plaintiffs prevailed on most issues in an decision that sheds light on Article III standing requirements and application of the futility doctrine." (Health Plan Law blog by Attorney Roy F. Harmon III)

[Opinion] Healthcare Reform -- Nobody's Asking the Hardest Question: Who Gets Care and When
Excerpt: "I believe that without a mechanism to control what care is available and to whom and at what time, costs will continue to be a problem. We have more technology than we can afford. In national health care systems care is rationed by either long waits or guidelines that restrict access." (Jeffrey Clayton on the BNA Pension & Benefits Blog)

High Healthcare Costs Caused in Part by Power of Healthcare Systems, Wisconsin Study Says
Excerpt: "High health care costs in the Milwaukee area stem from the market power of health care systems, according to a study by the Wisconsin Policy Research Institute. The study contends that health care systems have increased their market power by employing physicians, which gives them a referral base for their hospitals, which makes it harder for would-be competitors to enter the market." (Milwaukee Journal Sentinel)

Summary of the Colorado Managed Care Review 2007
Excerpt: "This is the 14th edition of Allan Baumgarten's annual analysis of trends and issues in the Colorado health care market. Baumgarten, an independent analyst and researcher on health finance in local markets has published his Colorado market study since 1994 He also publishes annual market reports in California, Florida, Illinois, Kentucky, Michigan, Minnesota, Ohio, Texas and Wisconsin. A new Arizona study will be published in 2008." (Allan Baumgarten)

[Guidance Overview] HMO Loses Third Party Beneficiary Contract Dispute With Health Care Providers
Excerpt: "In this health care provider versus HMO dispute, the providers chalked up a win. Having successfully moved for remand following the HMO's attempt to convert the payment controversy into an ERISA action, the HMO asserted ERISA preemption as an affirmative defense. The trial court, and subsequently, the appellate court, found this defense unavailing." (Health Plan Law blog by Attorney Roy F. Harmon III)

Shepherding Major Health System Reforms: A Conversation With German Health Minister Ulla Schmidt (PDF)
10 pages. Excerpt: "During her tenure with the German health ministry, Ulla Schmidt has overseen major system reforms, balancing social solidarity with fiscal responsibility." (Health Affairs)

A Living Model of Managed Competition: A Conversation With Dutch Health Minister Ab Klink (PDF)
8 pages. Excerpt: "The Dutch government's centrist approach to health reform with an individual insurance mandate could provide another model for U.S. reform efforts." (Health Affairs)

'Medical Home' Concept Embraced by IBM and Other Employers
Excerpt: "[T]he hallmarks of a 'medical home' are an ongoing relationship with a doctor; a team approach to delivering comprehensive, coordinated care that is integrated across the health care system; the use of tools, such as electronic medical records, to ensure that care is delivered safely and prevents redundancy and medical errors; and expanded access, including evening and weekend office hours and the use of e-mail and telephone consultations . . . ." (Financial Week; free registration required)

[Opinion] Bars to Managed Care Lawsuits - A Historic Review
Excerpt: "Historically, managed care companies have been afforded immunity from negligence and malpractice lawsuits. Several state and federal bars, including ERISA (Employee Retirement Income Security Act of 1974), have insulated managed care companies from liability relating to the treatment of patients. Likewise, managed care companies have historically been immune from malpractice committed by a health care member of its panel of providers." (The Executive Post @ Healthcare Financials.com)

Proposal Could Lift Fee Limits Imposed on HMOs by State of California
Excerpt: "The way that state regulators levy penalties and fees on HMOs is coming under intense scrutiny in the Capitol. And now one Democratic senator is trying to remove what is effectively a limit on fines against health providers." (Foundation for Taxpayer and Consumer Rights)

Health Insurance & Managed Care Compilation of Statistics and Articles Updated March 3
Excerpt: "For most Americans, market-based health insurance remains the predominant form of health coverage." (National Conference of State Legislatures)

Adviser Sheds Light on PBM Conflicts of Interest
Excerpt: "Fiduciaries could be breaching their responsibilities under ERISA if the revenue streams going to PBMs are not fully understood by the sponsor. Which begs the question: do your clients know about all the money you're making from their PBM relationship?" (Employee Benefit Adviser)

Adviser Sheds Light on PBM Conflicts of Interest
Excerpt: "Fiduciaries could be breaching their responsibilities under ERISA if the revenue streams going to PBMs are not fully understood by the sponsor. Which begs the question: do your clients know about all the money you're making from their PBM relationship?" (Employee Benefit Adviser)

Conversations on The Changing Face Of Managed Care: Insights from Managed Care Magazine's Podcast Series (PDF)
34 pages. Articles include 'Seeing Through Transparency [from the Employer's Perspective],' 'Electronic Health Information,' 'The Future of Disease Management' and 'Consumer-Directed Health Plans." (Managed Care)

Wal-Mart Signals Its Move Into the PBM Industry; Analysts Have Mixed Reactions
Excerpt: "Wal-Mart Stores, Inc.'s plan to start offering pharmacy benefit services to employers has provoked mixed reactions from PBM industry stakeholders. While some observers contend that any move by the retail behemoth has the potential to be an industry 'game changer,' two of the largest PBMs appeared unfazed by the prospect of a giant new competitor." (AISHealth.com)

Healthcare Data Pooling: Coming Soon to a Community Near You?
Excerpt: "Everyone can agree that quality healthcare is a good thing. But how do we go about measuring quality? Intrepid organizations in Massachusetts, Minnesota, Washington, and Wisconsin are answering the call for measurable quality metrics by developing data-pooling operations that can report on healthcare quality." (Milliman)

California Regulators Faulted for Altering State Law on HMO Guidelines
Excerpt: "Physician groups and patient advocates are criticizing the Department of Managed Health Care for failing to comply with a state law that seeks to improve timely access to care for HMO members, the Los Angeles Times reports." (California HealthCare Foundation; free registration may be required)

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